AJR 2005; 184:S118-S119
© American Roentgen Ray Society
Transhepatic Portal Venous Power-Pulse Spray Rheolytic Thrombectomy for Acute Portal Vein Thrombosis After CT-Guided Pancreas Biopsy
Glenn W. Stambo1 and
Leopoldo Grauer2
1 Division of Vascular and Interventional Radiology, Department of Radiology,
SDI Radiologists, St. Joseph's Hospital and Medical Center, 4516 N Armenia
Ave., Tampa, FL 33607.
2 Department of Gastroenterology, St. Joseph's Hospital and Medical Center, 3001
W Dr. Martin Luther King Blvd., Tampa, FL 33607.
Received February 10, 2004;
accepted after revision April 15, 2004.
Address correspondence to G. W. Stambo
(xraydoc2{at}yahoo.com).
Introduction
Fine-needle aspiration of the pancreas is a routine interventional
radiology procedure commonly performed under CT-guided imaging. The procedure
has a very low risk for complications, which can include hemorrhage,
infection, bowel perforation, and pancreatitis
[1]. Acute portal vein
thrombosis (APVT) arising from a pancreatic biopsy is an extremely rare
entity. One case has been described by Matsumoto et al.
[1] in a patient with
pancreatic neoplasm. Various articles have described percutaneous therapies
for portal vein thrombosis, including transjugular, transhepatic, and
intraarterial approaches using mechanical and pharmacologic strategies. We
describe a recent case of APVT secondary to CT-guided pancreatic biopsy; the
patient was subsequently treated using the emerging technique of power-pulse
spray thrombolysis. This technique, which combines mechanical and
pharmacologic thrombolysis in a power-pulse spray fashion, is becoming the
preferred treatment method for acute intravascular thrombosis, as it achieves
rapid dissolution of thrombus and restoration of luminal patency without the
need for surgical intervention.
Case Report
A 49-year-old man with a medical history significant for coronary artery
disease, myocardial infarction, and chronic pancreatitis presented to the
emergency department with acute onset midabdominal pain approximately 5 days
after a CT-guided percutaneous pancreatic biopsy. An emergent CT scan of the
abdomen revealed a large intraluminal thrombus consistent with portal vein
thrombosis.
The patient was brought directly to the interventional radiology suite and
a percutaneous transhepatic approach through the liver parenchyma was used to
gain access to the portal venous system. A 22-gauge Chiba needle was used to
gain access to the portal vein. A 7-French sheath was placed within the portal
vein. Portography confirmed occlusion of the portal vein secondary to the
large intraluminal thrombus (Fig.
1A). A 5-French Kumpe (AngioDynamics) catheter preloaded with a
steerable angled Glidewire (Terumo/Boston Scientific) was used to cross the
intraluminal thrombus and advance out into the distal superior mesenteric
vein. A 6-French Xpeedier AngioJet rheolytic mechanical thrombectomy catheter
system (Possis Medical) was advanced easily through the thrombosed portal
venous system deep into the distal superior mesenteric vein
(Fig. 1B).
The power-pulse spray technique was then performed using tissue plasminogen
activator (t-PA). The t-PA solution (10 mg/100mL) was instilled intraluminally
while retracting the catheter slowly and steadily through the clot back into
the sheath. A total dose of 5 mg was instilled into the portal venous system.
The t-PA solution was allowed to remain for 20 min. The AngioJet catheter was
used in the standard fashion as outlined by the manufacturer's protocol for
percutaneous thrombectomy. Multiple passes were made through the thrombosed
regions. Postpharmacomechanical thrombolysis venography showed improved
patency within the portal venous system. A 10 mm x 4 cm angioplasty
balloon (Bard Peripheral Vascular) was used to balloon macerate the residual
thrombus (Fig. 1C). Final
images showed complete clearing of the thrombus within the portal venous
system (Fig. 1D). On removal of
the 7-French sheath from the liver, the transparenchymal tract was embolized
with a combination of two 12 mm x 5 mm embolization coils (Cook) and
Gelfoam pledgets (Pharmacia, Upjohn). No transparenchymal tract bleeding was
identified after sheath removal. No postprocedure complications occurred. The
patient was discharged in 14 days after resolution of his other medical
issues. He remained symptom-free after 2 months.
Discussion
Although various authors
[2-8]
have described treatment approaches to portal vein thrombolysis, including
mechanical and pharmacologic strategies, to our knowledge, this is the first
case of power-pulse spray thrombolysis for the treatment of APVT initiated by
percutaneous pancreatic biopsy.
APVT is a rare event and a life-threatening emergency presenting with
progressive ascites and signs of intestinal ischemia
[5]. Mortality rates are 20%
with surgical intervention and anti-coagulation and up to 100% with no
intervention [6]. These
patients are at a high risk for hemorrhagic bowel infarction secondary to
venous outflow obstruction [3].
APVT can be triggered by cirrhosis, neoplasm, infection, coagulation
abnormalities, iatrogenic causes, and trauma
[4]. Matsumoto et al.
[1] describe portal vein
thrombosis initiated by a percutaneous pancreas biopsy.
We used a percutaneous transhepatic approach to the portal venous system
coupled with an emerging technique called power-pulse spray thrombolysis. This
technique combines the advantages of mechanical rheolytic thrombolysis and
catheter-directed pulse spray pharmacologic thrombolysis, collectively called
pharmacomechanical thrombolysis
[2]. In this case, we rapidly
and completely removed the acute portal venous thrombosis, restoring portal
venous patency with an excellent radiographic and clinical result. This quick
and precise percutaneous approach for treatment of portal vein thrombosis,
especially APVT, is critical for the treatment of this highly morbid
condition. Performed with conscious sedation only, percutaneous portal vein
cannulation and clot lysis can literally be initiated in a few minutes on
arrival to the vascular suite, providing almost immediate clot
dissolution.
The power-pulse spray technique has allowed interventionalists to rapidly
dissolve clots, which was previously performed with a hand-pulse spray
technique. The power-pulse spray distributes the pharmacologic agent rapidly
in a short burst of high-pressure pulses generated by the Possis machine out
through the AngioJet catheter tip. This is performed without a wire as a guide
so as not to occlude the end hole. With slow steady retraction of the catheter
while pulsing out the agent, the actual surface area that is covered is
greatly increased and provides instant clot disruption as a result of the
intense force at which the agent exits the catheter tip. Direct intravascular
clot disruption and high fibrin specificity for thrombus greatly improve the
clot lysis, rapidly restoring patency of the vessel. We believe endovascular
specialists should be aware of and become comfortable with power-pulse spray
thrombolysis, as it has become a powerful tool in the therapeutic
decision-making process now available for percutaneous intravascular
thrombolysis.
References
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Introduction
Case Report
